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Published on: June 12, 2021
Outcomes with invasive vs conservative management of cardiogenic shock complicating acute myocardial infarction
Sripal Bangalore1, Navdeep Gupta2, Yu Guo1
1New York University School of Medicine, New York.
Insights
Early invasive management significantly reduces in-hospital mortality for patients with cardiogenic shock complicating acute myocardial infarction. This approach benefits all patient groups, including the elderly, highlighting its critical role in improving outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Critical Care Medicine
Background:
- The SHOCK trial demonstrated a mortality benefit for early revascularization in cardiogenic shock post-myocardial infarction.
- Real-world data on invasive versus conservative management for cardiogenic shock is limited.
- Evaluating contemporary practice patterns and outcomes is crucial for patient care.
Purpose of the Study:
- To assess real-world outcomes of invasive versus conservative management in patients with cardiogenic shock.
- To compare in-hospital mortality rates between invasive and conservative strategies.
- To investigate outcomes across different patient subgroups, including the elderly.
Main Methods:
- Analysis of the Nationwide Inpatient Sample (2002-2011).
- Inclusion criteria: acute myocardial infarction with cardiogenic shock.
- Propensity score matching to compare invasive (cardiac catheterization, PCI, CABG) and conservative management groups.
- Primary outcome: in-hospital mortality.
Main Results:
- A cohort of 60,833 patients was identified; 20,644 were matched (10,322 per group).
- Invasive management was associated with 59% lower odds of in-hospital mortality (37.7% vs. 59.7%).
- Reduced mortality was consistent across subgroups, including elderly patients (≥75 years).
Conclusions:
- Invasive management significantly lowers in-hospital mortality in cardiogenic shock complicating acute myocardial infarction.
- This benefit extends to elderly patients, challenging previous assumptions.
- Aggressive management strategies are essential for this high-risk patient population.
Background:
In the SHOCK trial, an invasive strategy of early revascularization was associated with a significant mortality benefit at 6 months when compared with initial stabilization in patients with cardiogenic shock complicating acute myocardial infarction. Our objectives were to evaluate the data on real-world practice and outcomes of invasive vs conservative management in patients with cardiogenic shock.
Methods:
We analyzed data from the Nationwide Inpatient Sample from 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery) vs conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality.
Results:
We identified 60,833 patients with cardiogenic shock, of which 20,644 patients (10,322 in each group) with similar propensity scores, including 11,004 elderly patients (≥75 years), were in the final analysis. Patients who underwent invasive management had 59% lower odds of in-hospital mortality (37.7% vs 59.7%; odds ratio [OR] 0.41; 95% confidence interval [CI], 0.39-0.43; P < .0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (≥75 years) (44.0% vs 63.6%; OR 0.45; 95% CI, 0.42-0.49; P < .0001) and those younger than 75 years (30.6% vs 55.1%; OR 0.36; 95% CI, 0.33-0.39; P < .0001), although the magnitude of risk reduction differed (Pinteraction < .0001).
Conclusions:
In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup.
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